Public health

Latest ‘do-not-do’ list a missed opportunity to tackle opioids

A leading back expert has hit out at new ‘do-not-do’ lists for back pain, arguing they fail to address the deadly problem of opioid over-prescribing.

Professor Chris Maher said he was surprised to find spinal orthortics and bed rest included on the new RACP EVOLVE list of things to avoid when treating non-specific low back pain, rather than warnings not to prescribe opioid-containing analgesics, which pose a far greater threat.

The list, published this month, finds evidence for back braces is “insufficient and conflicting” and long periods of bed rest can be harmful.

But Professor Maher, director of Musculoskeletal Health Sydney at the Sydney School of Public Health at the University of Sydney, said these were “odd” choices, especially since back braces have gone out of fashion.

“One of the bigger issues is the liberal prescription of opioid medicines which can kill people. No-one is going to die from having a back brace put on. It’s a lost opportunity.”

Meanwhile, a second list was released by NPS Medicine Wise Choosing Wisely campaign on Monday, which also nominated five interventions to avoid, developed by the RACP’s Australasian Faculty of Occupational and Environmental Medicine.

This list does address opioid-containing analgesics, advising against prescribing them for chronic pain without assessing clinical condition, potential side effects, alternative medications, work status and capacity to perform safety-critical activities like driving.

But Professor Maher labelled the advice “weak and vague”.

“I am not sure it provides much guidance at all,” he said.

“Recent overseas guidelines for managing back pain provide much clearer messages about avoiding this medicine. The 2016 NICE guideline states ‘do not offer opioids for managing chronic low back pain”.

“The 2017 American College of Physicians (ACP) Guideline recommends that opioids are a last resort: only to be considered for chronic low back pain that has not responded to all other therapy options.

“The NICE and ACP guidelines suggest if you have a long-term back problem, the things you should be doing are exercise, psychological therapies, multidisciplinary rehabilitation. I think there is an opportunity to start promoting those.”


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